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Ovid: Atlas of Primary Care Procedures

Editors: Zuber, Thomas J.; Mayeaux, E. J. Title: Atlas of Primary Care Procedures, 1st Edition Copyright ©2004 Lippincott Williams & Wilkins > Table of Contents > Musculoskeletal Procedures > 66 – De Quervain’s Tenosynovitis Injection 66 De Quervain’s Tenosynovitis Injection Stenosing tenosynovitis of the short and long thumb abductor tendons (i.e., abductor pollicis longus and extensor pollicis brevis) is a common cause of dorsal wrist pain near the radial styloid. Commonly known as de Quervain’s tenosynovitis or disease, the condition probably is related to overuse and chronic microtrauma to the first dorsal compartment tendons as they pass through a fibro-osseous tunnel. Jobs that require repetitive hand and wrist motion, especially those with frequent thumb extension and extreme lateral wrist deviations, increase the risk of this disorder. Certain sports (e.g., golf, racquet sports, fishing) have also been commonly associated with the condition. Gonococcal infection historically was a cause of de Quervain’s disease, but this is a very uncommon cause today. De Quervain’s disease produces marked discomfort on gripping. Ulnar deviation, as reproduced with Finkelstein’s test, causes marked pain. Visible swelling often can be observed over the abductor tendons, and palpable crepitus may be observed. Pain, tenderness, swelling, and warmth over the dorsal wrist are common features on examination. Finkelstein’s test is the classic diagnostic maneuver to uncover the disorder. The differential diagnosis includes wrist arthritis, Wartenberg’s syndrome (i.e., radial nerve compression at the wrist), and intersection syndrome (i.e., tendonitis and associated bursitis of the dorsal wrist extensors). Corticosteroid injection can resolve or cure the condition, especially if given early in the course of the disease. Some physicians believe that injection therapy offers the best prognosis for improvement in symptoms. Many physicians prefer to postpone injections until a trial of physical therapy, antiinflammatory medication, and rest (with or without splinting or casting) have been prescribed. Up to three injections, given at monthly intervals, can be tried before surgical referral for release of the dorsal compartment. INDICATIONS

  • Clinically apparent de Quervain’s disease


  • Uncooperative patient
  • Bleeding diathesis or coagulopathy
  • Steroid administration if clinical appearance of gonococcal tenosynovitis
  • Bacteremia or localized cellulitis of wrist area
  • Uncontrolled diabetes

PROCEDURE The two abductor tendons of the thumb can be observed outlining the radial border of the anatomic snuff box. The tendons appear prominently when the thumb is fully abducted.

(1) Location of the two abductor tendons of the thumb: abductor pollicis longus tendon and extensor pollicis brevis tendon.

The thumb is flexed firmly into the palm (Figure 2A). The remaining four fingers close over the thumb, and then the wrist is deviated to the ulnar side (Figure 2B). Finkelstein’s test produces marked discomfort for most individuals with de Quervain’s disease.

(2) Finkelstein’s test.

Identify the point of maximal tenderness. After skin preparation, the needle enters the skin at a 45-degree angle (Figure 3A). The needle can enter the tendon sheath angled toward or away from the hand. Insert the needle until the tip is felt to touch the tendon; then withdraw the needle tip 1 to 2 mm. If the needle tip is within the tendon sheath, injection will offer no resistance, and the sheath can often be observed to distend with fluid (Figure 3B).

(3) Insert the needle at a 45-degree angle until the tip is felt to touch the tendon and then withdraw the needle tip 1 to 2 mm.

PITFALL: The tendon can be weakened by intratendinous injection. Avoid injecting directly into the tendon. If the physician is uncertain about the position of the needle tip, ask the patient to abduct the thumb; slight movement of the tendon produces marked movement of the syringe and needle. A bandage is placed over the injection site. Some physicians advocate limited activity and nighttime splinting for 1 to 2 weeks following the injection. Nonsteroidal antiinflammatory medications should be taken for at least 72 hours to reduce the incidence of postinjection flare (i.e., increased pain induced by the steroid crystals).

(4) Place a bandage over the injection site, and ask patient to limit activity and apply a splint at nighttime for 1 to 2 weeks following the injection.


CPT® CodeDescription2002 Average 50th Percentile Fee
20550*Injection of a tendon sheath or ligament$93
CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING Consult the ordering information that appears in Chapter 65. A suggested tray for performing soft tissue aspirations and injections is listed in Appendix D. Skin preparation recommendations appear in Appendix H. BIBLIOGRAPHY Anderson LG. Aspirating and injecting the acutely painful joint. Emerg Med 1991;23:77–94. Brown JS. Minor surgery: a text and atlas. London: Chapman & Hall Medical, 1997:165. Hanlon DP. Intersection syndrome: a case report and review of the literature. J Emerg Med 1999;17:969–971. Kay NR. De Quervain’s disease: changing pathology or changing perception? J Hand Surg Br 2000;25:65–69. Leversee JH. Aspiration of joints and soft tissue injections. Prim Care 1986;13:579–599. Mani L, Gerr F. Work-related upper extremity musculoskeletal disorders. Prim Care Clin Office Pract 2000;27:845–864. Marx RG, Sperling JW, Cordasco FA. Overuse injuries of the upper extremity in tennis players. Clin Sports Med 2001;20:439–451. Owen DS, Irby R. Intra-articular and soft-tissue aspiration and injection. Clin Rheumatol Pract 1986;Mar-May:52–63. Rettig AC. Wrist and hand overuse syndromes. Clin Sports Med 2001;20:591–611. Ritchie JV, Munter DW. Emergency department evaluation and treatment of wrist injuries. Emerg Med Clin North Am 1999;17:823–842. Weiss AP, Akelman E, Tabatabai M. Treatment of DeQuervain’s disease. J Hand Surg Am 1994;19:595–598.

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